Waitlist

Current Registration
Waiver
Complete

Parent/Primary Contact Information

First Name

Last Name

Suffix

Street Address

City

Postal Code

State/Province

Country

Email

Mobile Phone Number

Are you or your spouse/partner an active member of the military?

Yes

No

Service Branch

Participant Information

First Name

Last Name

Suffix

Gender

Birth Date

T-Shirt Size

Event

Participated in a Surfers Healing event before?

No

Yes

Registering Additional Campers with Autism?

If you wish to register additional campers (up to 3) please specify the required number and proceed. Please note that although we welcome the entire family to enjoy a day at the beach together, the surfing component of our camps is reserved exclusively for individuals with autism. (Our insurance does not cover neurotypical participants).

Number of Additional Campers

Participant Information

First Name

Last Name

Suffix

Gender

Birth Date

T-Shirt Size

Event

Participated in a Surfers Healing event before?

No

Yes

Participant Information

First Name

Last Name

Suffix

Gender

Birth Date

T-Shirt Size

Event

Participated in a Surfers Healing event before?

No

Yes

Participant Information

First Name

Last Name

Suffix

Gender

Birth Date

T-Shirt Size

Event

Participated in a Surfers Healing event before?

No

Yes

Please read carefully before proceeding

Parent/Primary Contact Information

Participant Information

Participant Information

Participant Information

Participant Information